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Texas Elder Abuse and Mistreatment Institute

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Title: Texas Elder Abuse and Mistreatment Institute


1
Texas Elder Abuse and Mistreatment Institute
2 -
2
Module 2 INTERVIEWING ELDERS, ELDERLY VICTIMS,
and PERPETRATORS Part A Geriatric Assessment
and Decision-making Capacity
  • E. Lee Poythress, M.D.
  • Baylor College of Medicine

2 -
3
Module 2 Objectives
  • Use general interviewing skills with the elderly.
  • Review the clinical interview and describe how it
    pertains to geriatric assessment and
    intervention.
  • Describe methods for determining mental capacity.
  • Define neutralization and its various types.
  • Demonstrate neutralization techniques.

2 -
4
Pre-Test Questions
  • 1. Which of the following is true regarding
    geriatric assessment and intervention (GAI)?
  • a. It is best applied in the hospital
    setting.
  • b. It can be performed by a licensed social
    worker.
  • c. It has been shown to delay diagnosis at
  • times.
  • d. It involves a comprehensive
  • multidimensional evaluation.
  • e. It is a proven intervention for elder
  • mistreatment.

2 -
5
Pre-Test Questions
  • In Texas, which of the following professionals
    can determine decision-making capacity?
  • a. Social workers
  • b. Police officers
  • c. Prosecutors
  • d. Physicians
  • e. Psychologists

2 -
6
General Approach to the Elderly Patient
  • Elderly patients often present with complex,
    chronic issues.
  • Elder mistreatment victims often live in
    precarious social situations.
  • Initial assessment can be a significant
    undertaking.

2 -
7
General Approach to the Elderly Patient
  • Allow for extra time on a visit or consider
    breaking up the visit into two closely spaced
    meetings.
  • 2. Geriatric Assessment Intervention (GAI)
    techniques are a structured way to evaluate the
    elderly.
  • 3. Autonomic dysfunction set room temperature
    at 70-80 degrees Fahrenheit.

2 -
8
General Approach (cont.)
  • 4. Aid vision and communication by using bright
    light and large-print literature and by sitting
    face to face.
  • 5. Presbycusis speak in a lower pitch without
    significantly raising the voice, sit face to
    face, and use headphones.
  • 6. Central processing auditory deficit quiet
    rooms.
  • 7. Privacy.

Cassel, 1997
2 -
9
General Approach (cont.)
  • 8. Normal aging comes with a slowing of
    performance, but not decreased cognition.
  • 9. Family members or caregivers often accompany
    patients. Remember to respect autonomy.
  • 10. Dementia or cognitive impairment does not
    mean incapacity.

2 -
10
The Clinical Interview and Geriatric Assessment
and Intervention
2 -
11
Clinical Evaluation GAI
  • Geriatric Assessment and Intervention (GAI)
  • Comprehensive history and physical.
  • Assessment of cognitive and functional status.
  • Full social evaluation.
  • Tailored items (Physical Therapy -Occupational
    Therapy screen, audiovisual screen, other).

2 -
12
Clinical Evaluation GAI
  • Usually composed of a team Medical Doctor,
    Nurse Practitioner, Physicians Assistant,
    Physical Therapist/Occupational Therapist, Social
    Worker, nurse managers, etc.
  • Shown in multiple care settings to improve
    outcomes, decrease readmission rates, and improve
    quality of life.
  • Office-based adjustments can be made.

2 -
13
Clinical Evaluation GAI
  • Primary care physicians may be reluctant to get
    involved in all forms of family violence (AMA
    Guidelines, 1992).
  • Time and reimbursement issues are real.
  • GAI can help with these matters.
  • Dont give up!

2 -
14
Clinical Evaluation GAI
  • Social History
  • Important for all forms of abuse and neglect.
  • Essential components
  • Living arrangements?
  • Home utilities working?
  • History of family violence?
  • Drug or alcohol use by patient or caregivers?

2 -
15
Clinical Evaluation GAI
  • Essential components
  • Finances/monthly income Who manages money (pays
    bills, cashes checks, etc.)?
  • Social contacts?
  • Food supply Who buys it? Who prepares it?
  • How did patient get to the clinic?

2 -
16
Clinical Evaluation GAI
  • Depression Screening and Cognitive and Functional
    Assessment
  • Key component of GAI.
  • Use of brief, accepted screening tools.

2 -
17
Clinical Evaluation
  • Other evaluations
  • Complete blood count
  • Serum chemistries
  • X-rays
  • Toxin screens
  • Drug levels

2 -
18
Conclusions
  • Interviewing elderly patients requires some
    adjustments in approach.
  • The theories and risk factors surrounding elderly
    mistreatment can act as important tools when
    evaluating patients.
  • GAI is an efficient and reliable way to evaluate
    elderly patients.

2 -
19
Decision-making Capacity
2 -
20
Decision-making Capacity
  • Competence refers to a persons capacity to
    make rational, informed decisions about his or
    her care. (Oyama O, 1999)
  • Medical competence refers to a persons ability
    to understand medical information and make
    informed medical decisions.
  • Competence legal term
  • Decision-making capacity medical term

2 -
21
Decision-making Capacity
  • Formal competence assessment usually takes place
    after evidence calls a patients capacity into
    question (in a medical setting).
  • Primary clinicians can perform assessment.


2 -
22
Decision-making Capacity
  • Competence is a legal determination based partly
    on a medical assessment.
  • Final ruling is judicial.
  • A person can have a mental health disorder, such
    as Alzheimers disease, and show signs of obvious
    impairment, and still be legally competent.


2 -
23
Methods of Competency TestingMiller, S.S. and
Marin, D.B. (2000)
  • Many instruments have been developed for
    assessing patients competence. There is no
    universal standard.
  • Physicians are primarily focused on medical
    decision-making capacity.

2 -
24
Methods of Competency Testing
  • Basic tenets of assessing medical decision-making
    capacity can be used to assess a patients
    capacity to make rational, informed decisions in
    other areas of life.
  • When filling out capacity assessment forms for
    court, you are asked to extrapolate.

2 -
25
Applebaum and Grisso, 1988
  • 1. Communicating choices.
  • 2. Understanding relevant information.
  • 3. Appreciating the situation and its
  • consequences.
  • 4. Manipulating information rationally.

2 -
26
Annas and Densberger, 1984
  • What is your present physical condition?
  • What treatment is being recommended for you?
  • 3. What do you and your doctor think might
    happen if you decide to accept the treatment?

2 -
27
Annas and Densberger, 1984 (cont.)
  • What do you and your doctor think might happen if
    you decide not to accept the treatment?
  • 5. What alternatives are available? What are the
    probable consequences of each one?

2 -
28
Documentation
  • Document using either the Applebaum and Grisso
    method or the Annas and Densberger method and
    address each topic as it pertains to your
    patient.

2 -
29
Conclusions
  • Primary care physicians can assess competence in
    most clinical situations.
  • There are no accepted standards for this.
  • Primary care clinician focuses on medical
    decision-making capacity but, in competency
    situations, will be asked to extrapolate.

2 -
30
Conclusions
  • Both the Applebaum and Grisso method and the
    Annas and Densberger method provide a solid
    framework for discussing patients medical
    decision-making capacity and court-evaluated
    competency.

2 -
31
Post-Test Questions
  • 1. Which of the following is true regarding
    geriatric assessment and intervention?
  • a. It is best applied in the hospital
    setting.
  • b. It can be performed by a licensed social
    worker.
  • c. It has been shown to delay early
    diagnosis
  • at times.
  • d. It involves a comprehensive
  • multidimensional evaluation.
  • e. It is a proven intervention for elder
  • mistreatment.

2 -
32
Post-Test Questions
  • In Texas, which of the following professionals
    can determine decision-making capacity?
  • a. Social workers
  • b. Police officers
  • c. Prosecutors
  • d. Physicians
  • e. Psychologists

2 -
33
INTERVIEWING ELDERS AND ELDERLY VICTIMSPart B
Fine-tuning the Interview of Elderly Victims and
Perpetrators
Gregory Paveza, M.S.W., Ph.D. School of Social
Work University of South Florida
2 -
34
Pre-Test Questions
  • 1.      The 5 Ps of assessment are
  •  
  • a.  Privacy, Pacing, Planning, Pitch,
    Punctuality
  • b.  Privacy, Pacing, Plumbing, Pitch,
    Personality
  • c.  Personhood, Pacing, Personality, Planning,
    Pitch
  • d. None of the above

2 -
35
Pre-Test Questions
  • 2. A classic neutralization technique is denying
    responsibility. The abuser
  •  
  • a. Makes the victim out to be the wrongdoer.
  • b. Says all people are hypocrites.
  • c. Suggests the abuse is the result of forces
  • beyond his or her control.
  • d. Believes that abuse is inconsequential if
  • no one is physically injured.
  • e.  Says that the abuse never happened.

2 -
36
Discovering the Problem
  • The problem may come to light when
  • you discover it.
  • the caregiver discloses it.
  • the patient discloses it.

2 -
37
Handling the Disclosure
  • Let the discloser speak.
  • Listen!
  • Dont be distracted.
  • Keep questions to a minimum.
  • Watch for nonverbal clues.
  • Accept natural silences.

2 -
38
Encouraging the Disclosure
  • Who?
  • What?
  • When?
  • Where?
  • How?

2 -
39
Personally Dealing with the Disclosure
  • Address confidentiality.
  • Remember, your clients are adults.
  • Respect your clients basic rights.
  • Dont jump to conclusions.
  • Avoid being judgmental.
  • Avoid making accusations
  • Observe the discloser.
  • Avoid panic/keep calm.

2 -
40
Personally Dealing with the Disclosure (cont.)
  • Avoid expressing shock or horror verbally or
    nonverbally.
  • Consult as needed.

2 -
41
Monitor Yourself
  • Pay attention to your own feelings of frustration
    or fatigue.
  • If you get angry and upset because the person is
    confused and does not understand, ask someone
    else to be your mediator or to participate.
    Remember the confusion is not deliberate,
    regardless of how lucid the person was in the
    past.

2 -
42
The 5 Ps of Assessment
  • Privacy
  • Pacing
  • Planning
  • Pitch
  • Punctuality

2 -
43
Interviewing the Suspected Abuser
  • Begin by saying
  • This is a standard part of the assessment.
  • You want to get all of the information.
  • Information is needed in order to provide
    services and help for the patient.

2 -
44
Critical Information
  • Is there a presence of
  • psychological, drug, or alcohol problems?
  • physical illness?
  • Does the caregiver have help?
  • Is there a perceived burden in care giving?
  • What is the caregivers perspective?
  • What is the level of dependence on the client
  • for finances?
  • for housing?
  • Gather details about possible exploitation.

2 -
45
Call the Question
  • Based on the information collected, do you
    believe abuse, neglect, or financial exploitation
    is occurring?
  • If so, what are the next steps?
  • Finally, document, document, document.

2 -
46
Neutralization
  • Neutralization is when someone engaging in
    delinquent behavior tries to justify it or make
    it acceptable.
  • The tendency to try to make unacceptable behavior
    neutral must be addressed.

2 -
47
Neutralization Techniques and Counters
  • Denial of Responsibility
  • Claim Abuse is accidental or the result of
    forces beyond the persons control.
  • Counter Confront the abuser with the truth the
    event could not have been an accident or caused
    by someone or something else.

2 -
48
Neutralization Techniques and Counters (cont.)
  • Denial of Injury
  • Claim The abuse is inconsequential because no
    one was really injured.
  • Counter Help the abuser to understand the nature
    of the injury in terms of emotional or financial
    consequences.

2 -
49
Neutralization Techniques and Counters (cont.)
  • Denial of the Victim
  • Claim The victim is the real wrong-doer.
  • Counter The victims behavior is not an issue.
    The abuser is responsible for harmful behavior
    over which he or she had control.

2 -
50
Neutralization Techniques and Counters (cont.)
  • Condemning the Condemners
  • Claim All people are hypocrites. All people do
    things that are wrong. People shouldnt stick
    their noses in someone elses business.
  • Counter Nobody is perfect. This does not lessen
    the seriousness of the offense or excuse it.

2 -
51
Neutralization Techniques and Counters (cont.)
  • Appealing to Higher Loyalties
  • Claim The victims loyalties are with me. Blood
    is thicker than water.
  • Counter Its still abuse, and the victim must be
    protected.

2 -
52
Neutralization Techniques and Counters (cont.)
  • Defense of Necessity
  • Claim The abuse was necessary to prevent some
    greater evil.
  • Counter The abuser could have chosen other ways
    to deal with the problem.

2 -
53
Neutralization Techniques and Counters (cont.)
  • Metaphor of the Ledger
  • Claim I deserve to have this be excused because
    of everything Ive done for him/her.
  • Counter No amount of bookkeeping justifies the
    abuse and the harm inflicted.

2 -
54
Final Thoughts
  • Working with disclosure is difficult. Make sure
    you have support.
  • Neutralization is common. Be prepared to deal
    with it.

2 -
55
Post-Test Questions
  • 1. The 5 Ps of assessment are
  •  
  • a.  Privacy, Pacing, Planning, Pitch,
    Punctuality
  • b.  Privacy, Pacing, Plumbing, Pitch,
    Personality
  • c.  Personhood, Pacing, Personality, Planning,
    Pitch
  • d. None of the above

2 -
56
Post-Test Questions
  • 2. A classic neutralization technique is the
    denial of responsibility. The abuser
  •  
  • a. Makes the victim out to be the wrong-
  • doer.
  • b. Says all people are hypocrites.
  • c. Says the abuse is the result of forces
  • beyond his or her control.
  • d. Believes abuse is inconsequential if no
    one is
  • physically injured.
  • e. Asserts that the abuse never happened.

2 -
57
Texas Elder Abuse and Mistreatment Institute
2 -
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